A Federal Court in Arkansas has determined that Aetna’s claim handling conduct in addressing a long term disability insurance claimant’s ongoing eligibility for benefits was an abuse of discretion. Aetna had originally determined that the claimant was eligible for short term disability insurance and paid benefits for that period of time, based upon the claimant’s orthopedic difficulties, including multiple level disc herniations, supported by MRI and numerous surgeries.
When considering the eligibility for long term disability insurance benefits, Aetna obtained a medical review from one of its stable of in-house medical providers, Dr. Martin Mendelssohn, who provided Aetna with an opinion that it could utilize to deny the claim for long term disability insurance benefits, after seeking and obtaining an addendum opinion from Dr. Mendelssohn.
The claimant appealed this determination to deny the long term disability insurance benefits, and submitted additional medical support for her claim. On appeal, Aetna obtained an opinion from a frequently utilized peer reviewing doctor, Dr. Stuart Rubin. Dr. Rubin formulated his opinion solely on the basis of the medical records, having never treated, examined or evaluated the claimant. Despite the lengthy medical history and prior surgeries, Dr. Rubin provided restrictions and limitations which would permit the claimant to work on a full time sustained basis. Aetna thus upheld its claim decision to deny long term disability insurance benefits.
The Court determined that Dr. Rubin failed to properly consider various supportive medical records, and that his report was “inconsistent and confusing”.
The Court also determined that Aetna had improperly determined the physical demand requirements of the claimant’s occupation.
As a result, the Court entered judgment in favor of the claimant and ordered Aetna to pay all outstanding long term disability insurance benefits to the claimant, and permitted the claimant to pursue her attorneys fees.
Phillips v. Aetna Life